General Information

Healthcare Provider Seen on Day of Visit
*Healthcare Provider Seen on Day of Visit

Your Provider

Friendliness/courtesy of your provider
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Explanations the provider gave you about your problem/condition
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Concern the provider showed for your questions or worries
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Providers efforts to include you in decisions about your treatment
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Instructions the provider gave you about follow-up care
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Your confidence in the provider
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Likelihood of your recommending this provider to others
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Your Appointment

Ease of making appointments by phone
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Appointment available within a reasonable amount of time
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Waiting time in the reception area
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Waiting time in the exam room
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Keeping you informed if your appointment time was delayed
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Our Staff

The courtesy of the person who took your call
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

The friendliness and courtesy of the receptionist
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

The helpfulness of the people who assisted you with billing
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

The professionalism of our lab or imaging staff
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Your Overall Satisfaction With

Our Practice
*

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

N/A

Comments

Any addtional comments? (Optional)

I agree to the following
*

Yes

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